President Obama joined Vice President Joe Biden on Jan. 16 to announce proposals against gun violence including a ban on assault weapons and high-capacity ammunition clips as well as a call for tougher background checks. Photo by Landov Media

Obama enlists doctors for gun violence prevention

■ The president reassures physicians that they can ask patients about guns in the home and inform authorities if they believe someone might harm others.

President Obama's multifaceted plan to reduce gun violence calls on physicians to play an important role in decreasing shooting deaths and injuries in communities nationwide.

The initiative, which was unveiled Jan. 16, one month after 20 first-graders and six adults were massacred at a Connecticut school, encourages doctors to talk to patients about gun safety and warn law enforcement about threats of violence.

Obama clarified that the Affordable Care Act does not prohibit doctors from discussing gun safety. He assured physicians that they can report credible threats of violence without fear of penalties from the Health Insurance Portability and Accountability Act Privacy Rule. He also authorized the Centers for Disease Control and Prevention to research the causes and prevention of gun violence, work that was suspended in 1996 after a National Rifle Assn.-backed push to block the study's funding.

The fact that the president's plan encourages physician discussions about gun safety sends a clear message to the medical community, said Mark Rosenberg, MD, president and CEO of the Task Force for Global Health, an Atlanta-based nonprofit public health organization. He also was director of the CDC National Center for Injury Prevention and Control when its gun research funding was eliminated. “The president is saying, 'This is an important part of your job, and we're not going to tie your hands behind your back,' ” he said.

What remains unclear for many physicians, however, is when exactly a patient's threat of violence becomes credible and necessary to report, medical experts said. Some doctors worry about liability risks if they don't report threats from a patient who ends up engaging in violence. There also are concerns about releasing patients' medical information to authorities when there is no true risk of violent activity, health professionals said.

“The challenge is that psychiatrists have a great deal of difficulty predicting dangerousness,” said psychiatrist Victor Fornari, MD. He is director of the division of Child/Adolescent Psychiatry at North Shore-LIJ Health System in New Hyde Park, N.Y.

Talking about guns with patients

Obama's plan, which is estimated to cost $500 million, consists of legislative proposals that need congressional approval and 23 executive actions he can implement on his own. Physicians discussing gun safety and reporting threats of violence are covered under the president's executive actions. The plan comes as the nation continues to grapple with how and why fatal mass shootings occur, particularly the killings at Sandy Hook Elementary School in Newtown, Conn., on Dec. 14, 2012.

After the incident, the American Medical Association and more then 50 other organizations and medical societies sent a letter to the president, House and Senate, offering their experience and expertise to help find solutions to gun violence. The letter also called for improved access to mental health services and strengthening the nation's assault weapons ban.

The AMA supports physician counseling on firearm safety to help prevent accidents among their patients. AMA President Jeremy A. Lazarus, MD, said the clarification from the president on the issue “reinforces the importance of unfettered medical discussions about relevant health and safety risks.” Studies show that individuals who receive physician counseling are more likely to adopt one or more safe-gun storage options, the AMA said.

“We need to counsel our families about how to keep our children safe,” regardless of whether that involves bicycles, guns or swimming pools, said Denise Dowd, MD, MPH, a pediatric emergency physician and director of research in the Division of Emergency and Urgent Care at Children's Mercy Hospitals and Clinics in Kansas City, Mo. She said Obama's clarification on this issue was needed, because some physicians were confused by language in the ACA that prohibits the collection of any data pertaining to firearm counseling.

Denver family physician Jeffrey J. Cain, MD, encourages physicians to give patients with well-visit appointments a questionnaire that includes asking if they keep firearms in their homes. Physicians should discuss safe storage of firearms with patients who say they have guns at their residences, said Dr. Cain, president of the American Academy of Family Physicians.

There has been at least one effort to prevent doctors from asking patients about guns in the home. Under a 2011 Florida law, physicians who asked patients about gun ownership without justification, entered unnecessary information about such ownership in medical records or discriminated against gun-owning patients faced possible sanctions by the state medical board. In a Sept. 14, 2011, opinion, U.S. District Judge Marcia G. Cooke threw out the law. The state has appealed that decision to the 11th U.S. Circuit Court of Appeals.

Reporting threats of violence

Another key responsibility of health professionals is reporting direct and credible threats of violence to authorities, according to Obama's plan. The initiative clarified that HIPAA allows doctors to disclose patient information, including details of mental health records, to law enforcement and others who might be able to prevent or lessen the risk of harm.

Health professionals traditionally have had the flexibility to handle patients' threats of violence as they saw fit, such as through hospitalizing the individual or prescribing medicine, said psychiatrist Paul S. Appelbaum, MD, director of the Division of Law, Ethics and Psychiatry at Columbia University Medical Center in New York.

New York's newly tightened gun-control law, which was enacted Jan. 15, mandates that mental health professionals report such threats as a first step, rather than a last resort, he said. New York was the first state to pass stricter gun measures after the Connecticut shooting.

“A major concern is that patients who are thinking about hurting themselves or other people will decline to come to treatment or decline to talk about their thoughts for fear that their names are going to be turned over to the state,” said Dr. Appelbaum, a past president of the American Psychiatric Assn.

Obama's plan also calls for a series of mental health measures, including training more mental health professionals to care for youths, ensuring that students with signs of mental illness are referred to treatment and finalizing requirements for private health insurance plans to cover any mental health services at the same level as other medical benefits.

Dr. Rosenberg encourages health professionals and the public to understand that there is no simple solution to gun violence. But he said research, now reinstated to the CDC by the president, will be the key to finding ways to resolve the problem. “We've lost a lot of time and lives,” Dr. Rosenberg said. “But the good thing is we're getting back on track.”

ADDITIONAL INFORMATION

Obama's proposals to reduce gun violence

President Obama's initiative to reduce gun violence asks physicians to play an important role in decreasing shooting deaths and injuries in communities nationwide. Many of the executive orders and legislative proposals address clinical health and public health issues.

Executive actions

Issue a Presidential Memorandum directing the Centers for Disease Control and Prevention to research the causes and prevention of gun violence.

Clarify that the Affordable Care Act does not prohibit doctors from asking patients about guns in their homes.

Release a letter to state health officials clarifying the scope of mental health services that Medicaid plans must cover.